Transabdominal cervico-isthmic cerclage in the management of cervical incompetence

European Journal of Obstetrics & Gynecology and Reproductive Biology 72 (1997) 127 130

ELSEVIER

oa m GYNECOUIGY

Transabdominal cervico-isthmic cerclage in the management of cervical incompetence George S. A n t h o n y ~'*, Robert G. Walker ~', Alan D. Cameron b, John L. Price c, James J. Walker d Andrew A. Calder e ~ Rankm Maternin' Unit, Greenock, UK ~' Queen Mother ~" Hospital, Glasgow, (,'I~ " Bells~all] Maternit.v Hospilal, Bells~d/l. (,'K d St. James Ho.spita/. Leeds, t ' K e Simpson Memorial Maternity Pavilion. Edinhurgh, UK

Received 3 May 1996: received in revised form 18 July 1996: accepted 15 November 1996

Abstract

The use of transabdominal cervico-isthmic cerclage is described in 13 patients with a diagnosis of cervical incompetence. The patients were recruited from seven Scottish Maternity Units over a period of 10 years. The 13 patients have had a successful pregnancy in 86.6% of pregnancies with this procedure compared with a success rate of 16% in their previous pregnancies. In carefully selected cases transabdominal cervico-isthmic cerclage is a worthwhile procedure in patients with cervical incompetence when the cervix is so damaged that it would be impossible to insert a vaginal suture or when a vaginal suture has previously failed. ~:~ 1997 Elsevier Science Ireland Ltd.

Keywords: Transabdominal cervico-isthmic cerclage; Management: Cervical incompetence

I. Introduction

2. Patients and methods

Cervical incompetence predisposes patients to recurrent mid trimester abortion and premature delivery. While the majority of patients with cervical incompetence are suitable candidates for vaginal procedures, patients with a very short cervix or a deeply lacerated cervix cannot be treated by this approach. Transabdominal cervico-isthmic cerclage was described by Benson and Durfee [1] for patients with short or lacerated cervices. Although several centres have used this technique it has not been widely used in the UK. This paper describes the use of the technique in 13 patients with bad obstetric histories due to cervical incompetence.

Thirteen patients with a history suggestive of cervical incompetence were selected for transabdominal cervicoisthmic cerclage when a previous vaginal suture had been unsuccessful or where the cervix was so lacerated that it was felt that it would not be possible to insert a vaginal suture. In nine of the cases the diagnosis of cervical incompetence was confirmed by measurement of cervical resistance index (CRI) [2]. Transabdominal cervico-isthmic cerclage was performed at 12 14 weeks gestation after fetal viability had been confirmed by ultrasound. |ndomethacin 100 mg suppositories were administered the evening before and on the morning of the operation. The abdomen was opened through a low transverse incision and the periloneum over the lower part of the uterus opened. The bladder was mobilised and the uterine artery iden-

* Corresponding author.

0301-2115/977517.00 ~ 1997 Elsevier Science Ireland Ltd. All rights reserved. PII S 0 3 0 1 - 2 1 1 5 ( 9 6 ) 0 2 6 6 9 - 3

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G.S. Anthony el al. European Journal o! Obstetrics & GvnecolojLv and Reproductil,e Biolog) 72 (1997) 127 130

tiffed on each side, an artery forcep was used to create a 'tunnel' medial to the uterine artery and vein through to the peritoneum on the posterior surface of the uterus above the level of the cardinal ligaments. The suture (mersilene 5 m m tape) was led through from the posterior surface of the uterus and the procedure repeated on the opposite side (Fig. 1). The suture was tied anteriorly and the visceral peritoneum reconstituted [3]. Routine post-operative care was given and Indomethacin was administered rectally in three cases and orally in eight patients. One patient was treated with intravenous Ritodrine and then oral therapy. Tocolytic therapy was continued until at least 30 weeks gestation. One patient received tocolytic therapy only for the immediate post-operative period. In all patients delivered by lower uterine segment caesarean section the suture was left in place at delivery.

3. Results

Prior to the pregnancies which are described, these 13 patients had had a total of 50 pregnancies: 26 spontaneous mid-trimester abortions (range, 1-4): eight live children and six neo-natal deaths: five from prematurity at 24, 25, 25, 26 and 29 weeks gestation and one from spina bifida after delivery at 36 weeks gestation. These patients have now had 15 pregnancies, 13 successful and two unsuccessful (Table 1). One patient (case 4) has had two successful pregnancies and has now been sterilised. Patient 6 has had one successful pregnancy followed by an unsuccessful pregnancy during which she ruptured her membranes at 16 weeks gestation and 3 days later began to contract. A colpotomy was performed under general anaesthesia and the suture was divided but no attempt was made to remove the suture. The cervix immediately dilated to 6 cm and the uterus was then evacuated. Patient 10 was admitted at 36 weeks with a ruptured uterus and delivered a fresh stillborn child, the uterus was repaired and the suture remains in place. She had been delivered by classical caesarean section at 27 weeks when premature labour began with a breech presentation in her previous pregnancy. All patients were delivered by caesarean section when the suture was left undisturbed. Nine patients had an elective section, while four required delivery by emergency section: two when premature rupture of the membranes was followed by uterine activity at 33 and 35 weeks gestation and one when uterine activity commenced at 34 weeks. Emergency delivery was required in the patient whose uterus ruptured, One patient had a blood loss at operation of 1300 ml and required transfusion. In this case the bleeding arose during the creation of the tunnel medial to the uterine

vessels on the side where the cervix had previously been lacerated. One of the patients receiving Indomethacin developed oligohydramnios at 26 weeks gestation and was changed to oral Ritodrine. Interestingly this was the patient who had two pregnancies and in her second pregnancy Indomethacin was again used but oligohydramnios did not develop. The last four patients have not had "tunnelling' carried out and the suture has been inserted with an atraumatic needle [4]. This technique is less traumatic and leads to less blood loss at operation.

4. Discussion

It is crucial that cases such as those described are thoroughly investigated tbr a diagnosis of cervical incompetence. In nine out of the 13 cases cervical resistance studies were performed in the non-pregnant state. The possibility of damaging the gestation sac during the procedure was felt to preclude its use in pregnancy [2]. It has been shown that the CRI is higher in non-pregnant patients compared with pregnant patients, thus if the CRI is low in the non-pregnant state it will be even lower during pregnancy [5]. Cervical resistance tests confirmed a diagnosis of cervical incompetence in all nine cases. Once the diagnosis has been made, the normal practice is to offer cervical cerclage in a subsequent pregnancy, the preferred approach being via the vagina. The M R C / R C O G trial has shown a beneficial effect when cervical cerclage is performed in patients with a history suggestive of cervical incompetence [6]. In nine of the cases described, vaginal cerclage procedures had previously been unsuccessful, while in six out of the 13 cases there was evidence of a severely damaged cervix and in case 1 an attempt had been made to correct this by trachelorrhaphy but the CRI indicated that cervical incompetence remained after this procedure.

//OA

CL

USL

Fig. 1. Anatomy of the cervico-isthmicjunction. CL, cardinal ligament: SL. utero sacral ligament: UA. uterine artery.

G.S. Anthony eta/.

European Journal O~ Ob.~tetrics & Gynecology and Reproductive Biology 72 (1997) 127 130

129

Table I Outcome of pregnancies Case

Age

Previous pregnancies

Live births

1 2 3 4

27 3(! 36 21

3 2 2 3

I I" I 0

5 6

37 32

3 3

0 0

Gestation previous mid-term losses Trauma

19:20 18:25 20 19;20;22

Previous cerclage

Outcome

Cx tear (a~c:s Cx tear(ac/s Cx tear No

1 No I 1

C S @ 37 C S @ 38 Emer C/S @ 35 C S (~, 37

Cx flush Cx tear

1 No

C S @ 38 Emer C,'S @ 33

c:s ,~ 35 18:22 20:21

SRM @16/52 Colpotomy and evacuation of uterus 7 1 13:16:17:20 7 28 4 2 18:24 8 27 4 1~ 13:20 9 28 3 1~ 22:26 10 34

Cx tear Cx tear No No

c s ,~.~38 c s (~ 38

Ruptured uterus: previous classical C'S 11 ='~7 4 I ~' 12 39 9 4b I3 33 3 I

No No Laser to cx

Emer C,,'S @ 34 C S (a; 38 C S (u! 38

20:20:23 15:18:24 22

C S @ 38 SB (a, 36

No

~ Neo-natal death. b Two neo-natal deaths.

Rupture of a caesarean section scar is four times more likely after a classical section compared to a lower uterine segment section [5]. Scar rupture usually occurs suddenly without warning in the antenatal period and is often associated with fetal death. Myerscough [8] records one case of rupture of the uterus in a patient who had undergone cervical cerclage, but this was thought to be due to failure to remove the Shirodkar suture when labour commenced. In case 10 the uterine rupture almost certainly occurred due to weakness in the classical scar rather than as a result of obstructed labour due to the presence of the transabdominal suture. It may be technically difficult to carry out a lower uterine segment caesarean section when delivering very premature infants but the danger of rupture of a classical scar should be borne in mind. If possible, a vertical incision in the lower segment is preferable to a classical scar in the upper segment of the uterus. There is only one other series of the use of transabdominal cervico-isthmic cerclage from the U K [7]. In this series of 50 patients, Gibb removed the suture at caesarean section unless the patient expressed a wish to have further pregnancies [9]. It is always difficult for patients who have experienced a catastrophic obstetric history to be certain of their future obstetric aspirations at delivery and we therefore feel that it is wiser to leave the suture in place at delivery than remove it and perhaps have to undertake a further insertion if the patient decides to embark on another pregnancy. Gibb advocates tying the knot posteriorly and while this does make removal easier it does increase the possibility of adhesions developing around the suture and this could lead to future infertility. When the knot is tied anteriorly it is covered by the visceral peritoneum and should

not give rise to adhesions, although Novy [4] did report one case in 404 patients of a bladder fistula when the knot was tied anteriorly. The use of tocolytic therapy to cover the time of insertion of the suture is probably a wise precaution but it may be unnecessary to continue treatment until 30 weeks although in dealing with such anxious patients there is a tendency to use a 'belt and braces' approach. Novy [4] reviewed nine reports on the use of transabdominal cervico-isthmic cerclage in which 111 patients had 130 pregnancies with 89% fetal survival, this compared favourably with 21% survival in the pregnancies before abdominal cerclage was performed. In this series the fetal survival is 86.6% compared to 16.0% before abdominal cerclage was utilised. The cases treated in this series have been gathered over an ten year period in seven hospitals across Scotland, illustrating the highly selective nature of the problem. We would recommend that transabdominal cervicoisthmic cerclage be considered in carefully selected patients with cervical incompetence when the cervix is so damaged that a vaginal approach is not possible, or when a previous vaginal suture has been unsuccessful.

Acknowledgements We are grateful to Dr H.P. McEwan, Glasgow Royal Maternity Hospital, Dr W.A. Liston, Simpson Memorial Maternity Pavilion, Edinburgh, Dr C.H. Baird, Ayrshire Central Hospital, Irvine, Dr R. Cassie, Bellshill Maternity Hospital, Lanarkshire and Dr N. Kenyon, Vale of Leven Hospital Dunbartonshire for referring their patients for this procedure.

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G.S. Anthony el al. European Journal c~! Obstetrics & Gynecology and Reproductive Biology 72 (19971 127 130

References [1] Benson RC and Durfee RB. Transabdominal cervico-uterine cerc]age during pregnancy for the treatment of cervical incompetence. Obstet Gynecol 1965: 25:145 155, [2] Anthony GS, Calder AA and Macnaughton MC. Cervical resistance in patients with previous spontaneous mid-trimester abortion. Br J Obstet Gynaecol 1982: 89:1046 1049 [3] Anthony GS and Price JL. Successful use of transabdominal isthmic cerclage m the management of cervical incompetence. Eur J Obstet Gynecol Reprod Biol 1986; 22:379 383 [4] Novy MA. Transabdominal cervicoisthmic cerclage: A reappraisal 25 years after its introduction, Am J Obstet Gynecol 1991: 164: 1635 1642.

[5] Anthony GS, Fisher ,1~ Coutts JRT and Calder AA. Forces required for surgical dilatation of the pregnant and non pregnant human cervix. Br J Obstet Gynaecol 1982: 89:913 916 [6] MRC/RCOG Working Party on Cervical Cerclage. Final report of the Medical Research Council/Royal College of Obstetricians and Gynaecologists: multicentre randomised trial of cervical cerclage. Br J Obstet Gynaecol 1993: 100. 516 523. [7] Dewhurst CJ. The ruptured caesarean section scar. J Obstct Gynaecol Br Commonw 1957: 64; 113 118. I8] Myerscough PR. Munro Kerr's Operative Obstetrics, 10th edn. London: Balliere Tindall 1982:441 443, [9] Gibb DMF and Salaria DA. Transabdominal cervicoisthmic cerclage in the management of recurrent second trimester miscarriage and preterm delivery. Br J Obstet Gynaecol 1995; 102:802 806n